The Heights Of Bulverde

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents right to request to formulate an advance directive and accurate documentation of advance directives was maintained and implemented for 1 of 4 residents (Resident #53). Resident #53's OOH-DNR was signed and in misc. documents while face sheet and care plan were listed as full code. This deficient practice could place the resident at risk of receiving care inconsistent with their wishes. The findings were: Record review of Resident #53's face sheet revealed an [AGE] year-old male admitted on [DATE]. Diagnoses included Senile Degeneration of the Brain (a decline in cognitive function, particularly memory and thinking skills), Dementia (progressive or persistent loss of intellectual functioning) Depression (mental health disease of high and low mood swings), Anxiety (intense, excessive, and persistent worry and fear). Record review of Quarterly MDS assessment dated [DATE] revealed BIMS (Basic Interview of Mental Status) Score of 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #55) reviewed for care plans. The facility failed to ensure Resident #55 was provided a pad type call light which was care planned as an intervention for the resident. This deficient practice places residents at risk for not receiving proper care and services due to not implementing care plan interventions. The findings were: Record review of Resident #55's face sheet, dated 06/23/2025, revealed he was admitted on [DATE] with diagnoses which included: muscle wasting and atrophy, not elsewhere classified, multiple sites, multiple sclerosis (…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure medication error rates are not 5 percent or greater for 1 of 4 residents (Resident #19), reviewed for pharmacy services in that the automatic calculation of the medication error rate in the Long-Term Care Survey Process (LTCSP) after 25 opportunities with 2 errors was 8%. LVN A poured two different over the counter bulk facility medications into her bare hand to administer to Resident #19 and put the ones she did not need back into the bottle during a medication administration observation. This failure could place residents at risk of cross contamination, health complications, and illness. The findings were: Record review of Resident #19's face sheet dated 6/25/25 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with readmission on [DATE]. Her diagnoses included unspecified protein-calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands), and immunodeficiency due to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to store medication with the expiration date on packaging in compliance with state laws and regulations for 1 of 2 medication rooms (300/400 hall) observed for medication storage. The medication room on the 300/400 hall had a box with an [NAME] boot stored without an expiration date. This failure could affect residents prescribed medications and result in less potent medications provided and could result in decreased health response or misuse of medication. The findings included: Interview and observation of medication storage room for 300/400 halls on 06/23/25 at 09:00 AM revealed the date was torn off a box with an [NAME] boot (a wet compression dressing used in the treatment of venous ulcers and dries semirigid similar to a cast) and no date was on the foil package with the [NAME] boot. The DCO took the box with the [NAME] boot and discarded it in the trash. She said she did not know why the package date was torn off that way and she did not know why…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 4 residents (Resident #53) reviewed for accuracy of records. The facility failed to ensure Resident #53 expressed Full Code status and the code status documented in the electronic medical record, placing the resident at risk of receiving improper treatment. These failures could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #53's face sheet revealed an [AGE] year-old male admitted on [DATE]. Diagnoses included Senile Degeneration of the Brain (a decline in cognitive function, particularly memory and thinking skills), Dementia (progressive or persistent loss of intellectual functioning) Depression (mental health disease of high and low mood swings), Anxiety (intense, excessive, and persistent worry and fear). Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #19) reviewed for infection control. LVN A poured two different over the counter bulk facility medications into her bare hand to administer to Resident #19 and put the pills she did not need back into the bottle during a medication administration observation. This failure could place residents at risk of cross contamination, health complications, and illness. The findings were: In an observation and interview on 6/24/25 at 6:36 a.m. during a medication administration observation for Resident #19, LVN A poured several cyanocobalamin (Vitamin B12) 1000mcg oral tablets from a bulk facility stock bottle (unknown amount) into her bare left hand and tilted her left hand against the bottle and put all the tablets back in the bottle except one that she had in her creased palm to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 2 of 3 residents (Resident #1 and Resident #2) reviewed for clinical records. 1. The facility failed to ensure Resident #1's [EMR] Skin & Wound- Total Body Skin Assessments were documented in her medical record for 5 (the weeks of: 01/03/2025, 01/17/2025, 01/31/2025, 02/14/2025, and 04/04/2025) of 16 weeks. 2. The facility failed to ensure Resident #2's [EMR] Skin & Wound- Total Body Skin Assessments were documented in her medical record for 3 (the weeks of 01/14/2025, 01/28/2025, and 02/11/2025) of 15 weeks. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. Findings included: 1. Record review of Resident #1's admission Record, dated 04/23/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and Resident #2) of 3 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #1 was coded on her Annual MDS assessment, signed as completed on 04/21/2025, for a fall without injury that occurred on 02/03/2025. 2. The facility failed to ensure Resident #2 was coded on her Quarterly MDS assessment, signed as completed on 03/09/2025, for two falls without injury, 02/09/2025 and 02/14/2025, and one fall with an injury (not major), 02/25/2025. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #1's admission Record, dated 04/23/2025, reflected a [AGE] year-old female. She was initially admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to in accordance with accepted professional standards and practices, the facility must maintain records that are complete, accurately documented temperature for 1 of 1 kitchen reviewed. 1. The facility failed to ensure temperatures were taken and accurately logged for the 04/13/25 Breakfast and Lunch meals 2. The facility failed to ensure temperatures were taken and accurately logged for meals on 04/15/25 3. The facility failed to ensure temperatures were taken and accurately logged for for breakfast milk or juices from 04/13/2025 through -04/19/2025 These deficient practices could place residents at risk of serious illness related consuming meals that are prepared in an unsanitary manner. The findings were: Observation on 04/19/25 at 11:44 AM, [NAME] A did temperature checks before lunch meal service. Interview with [NAME] B on 04/19/2025 revealed revealed Dietary Aide E missed the temperatures on 04/13/25 and [NAME] D was supposed to put the temperatures in on 04/15/25. [NAME] B revealed the dietary supervisor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency for 2 of 8 Residents (Residents #1 and #2) who were reviewed for abuse, in that: 1. The facility failed to report an allegation of abuse or neglect per facility policy to the State Survey Agency (HHSC) when Resident #1 died after ingesting and choking on wet wipes. 2. The facility failed to report to the State Agency an injury of unknown origin and was suspicious of abuse/neglect for Resident #2. This deficient practice could affect any resident and could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed, in response to allegations of neglect, have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator and to other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident for 1 of 4 (Resident #2) residents reviewed for abuse, neglect, and exploitation investigations. The facility failed to investigate an injury of unknown origin sustained by Resident #2 that was suspicious of abuse or neglect. This failure could cause diminished quality of life and place residents at risk for mistreatment. Findings included: Record review of Resident #2's face sheet dated 3/19/2025 reflected an [AGE] year-old female with an initial admission date of 9/18/2023. Relevant diagnoses included unspecified dementia (progressive disorder that impairs thought processes, such as memory, thinking, reasoning, and decision-making), cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 6 residents (Resident #2) reviewed for care plan revision/timing. The facility failed to ensure Resident #2's care plan addressed newly developed pressure wound for 40 days after initial assessment. The noncompliance was identified as PNC. The noncompliance began on 11/14/2024 and ended on 12/24/2024. The facility had corrected the noncompliance before the survey began. This failure put the resident at risk for declining health due to specific needs being unaddressed or unmet by lack of care planning. Findings were: Record review of Resident #2's face sheet dated 3/19/2025 reflected an [AGE] year-old female with an initial admission date of 9/18/2023. Relevant diagnoses included unspecified dementia (progressive disorder that impairs thought processes, such as memory, thinking, reasoning, and decision-making), cognitive communication deficit (impairment in the thought processes that can impact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, the facility failed to maintain an infection prevention program to help prevent the development and transmission or communicable diseases and infections for 1 of 2 residents (Resident #3). The facility also failed to handle and transport linens so as to prevent the spread of infections for infection control practices. 1.The facility failed to ensure CNA FF utilized appropriate PPE when providing direct care to Resident #3, who had been identified as requiring enhanced barrier precautions. 2.The facility failed to ensure CNA M removed soiled gloves prior to exiting a room, as well as securing soiled linen in a bagged or contained method at the point of collection prior to transporting. These failures could lead to the spread of infection. Findings included: Record review of Resident #3's face sheet dated 3/20/2025 reflected an [AGE] year-old male admitted on [DATE] with diagnosis of senile degeneration of brain (a progressive disorder that impairs the thought…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (Resident #1 and Resident #3) reviewed for comprehensive care plans, in that: 1. The facility failed to ensure Residents #1's care plan reflected using a sit-to-stand lift for Resident #1 only when holding the resident to standing position from sitting position for ADL care, including shower. 2. The facility failed to ensure Residents #3's care plan reflected the need for substantial asssitance with eating. These deficient practices place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: 1. Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 12 residents (Residents #2 and Resident #3) reviewed for the provision of routine and emergency drugs and biologicals, in that: 1. Resident #2 did not receive her morning dose of antianxiety medication (busPIRone HCL for anxiety) because of lack of communication between a nurse and a CMA regarding the resident's out on pass for appointments. 2. Resident #3 did not receive her fentanyl patch for pain relief as ordered on 1/3/2023, 2/05/2023, 3/30/2023, 4/02/2024, and 5/17/2024. These failures could place residents at risk for harm by adverse reactions and not receiving the intended therapeutic effects of their medications. The findings included: 1. Record review of Resident #2's face sheet, dated 07/18/2024, revealed Resident #2 was admitted on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

FACILITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed, in that: 1. The walk-in freezer container approximately twenty-five boxes of frozen foods which were stored on the floor and haphazardly stacked on top of each other. 2. The reach-in refrigerator near the kitchen door contained a bottle of soda which belonged to a staff member. 3. The floor under the three-part sink in the dish room was soiled with a dark brown substance that appeared to be dirt or mud. 4. The walls throughout the kitchen were soiled with substances of various color. 5. The commercial toaster was soiled with an abundance of crumbs. 6. The microwave was soiled inside on all sides, the bottom, and the roof. 7. The fryer was soiled with an abundance of crumbs and the front and sides of the fryer were soiled with cooking oil. 8. The machines on either side of the fryer were soiled with an abundance of cooking oil. 9. The top and sides of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster site reviewed, in that: The area near the facility's two dumpsters was soiled with spilled kitchen oil and other refuse. This deficient practice could lead to an unsanitary environment and encourage the presence of pests. The findings were: Observation on 05/03/2024 at 4:40 p.m., of the area near the facility's two dumpsters revealed two, forty-gallon drums were located behind the facility dumpsters. The lids of both drums were loose and used fryer oil had spilled from the drums onto the ground underneath, beside, and in front of the facility dumpsters. Further observation revealed a large kitchen cooking pot with no lid and full of used fryer oil was also located behind the dumpsters. Further observation revealed the presence of assorted bits of paper, cardboard, and other refuse on the ground in the dumpster area. During an interview with the Dietary Manager, at the same time as the observation, the Dietary Manager stated he was new in his position…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for 3 of 3 residents reviewed (Resident #235, Resident #236, and Resident #237 ) who received Medicare skilled services and were discharged with benefits remaining, in that: 1. Resident #235 was not given a NOMNC upon discharge from skilled services. 2. Resident #236 was not given a NOMNC upon discharge from skilled services. 3. Resident #237 was not given a NOMNC upon discharge from skilled services. This deficient practice could affect residents who were discharged from skilled services with benefits remaining by denying them the right of appeal. The findings were: 1. Record review of Resident #235's closed record revealed the resident was not given a NOMNC upon discharge from skilled services on 04/06/2024. 2. Record review of Resident #236's closed record revealed the resident was not given a NOMNC upon discharge from skilled services on 04/04/2024. 3. Record review of Resident #237's closed record revealed the resident was not given a NOMNC upon discharge from skilled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide necessary services to maintain good grooming, personal hygiene for residents who were unable to carry out activities of daily living for 3 of 8 Residents (Resident #182, Resident #183, and Resident #184) whose records were reviewed for grooming and personal hygiene. The facility failed to ensure: 1. Resident #182 received scheduled showers on 4/29/24 and on 5/1/24. 2. Resident #183's dirty t-shirt was changed out on 5/1/24. 3. Resident #184's face had not been shaved, his eyebrows and nose hair had not been trimmed since 4/30/24. These deficient practice could affect any resident and contribute to feelings of poor self-esteem and hopelessness. The findings were: 1. Review of Resident #182's face sheet, dated 5/3/24, revealed she was admitted to the facility on [DATE] with diagnoses including Depression Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Generalized Anxiety Disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to ensure residents' environment remained as free of accidents and hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for 6 of 20 residents (#1, #3, #27, #39, #46 and #185 ) reviewed for assistance with safe mechanical lifts and falls. 1. On 05/05/2024 at 03:54 PM CNA R transferred Resident #39 from her bed to her wheelchair with the assistance of 1 person and caused Resident #39 discomfort and pain. 2. On 04/16/2024 The facility assessed 4 residents (#1, #3, #27, and #46) with the need for a mechanical lift and planned for residents to receive assistance with mechanical lifts with the aid of 1 person. 3. Resident #185 fell multiple times and on 4/21/24 sustained a laceration which required multiple sutures to the left side of her head. Staff failed to implement fall mats upon admission even though she was assessed to be a high fall risk and had a fall history prior to her admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 10%, based on 3 errors out of 30 opportunities which involved 2 of 8 residents (Resident #46 and #285) reviewed for medication administration and medication errors. 1. On 05/04/2024 at 07:31 AM LVN U failed to perform a safety check on the insulin injection pen prior to administering Resident #285's insulin injection. 2. On 05/04/2024 at 09:40 AM Medication Aide V administered Resident #46's antibiotic and nerve pain medication 40 minutes late. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #285's admission record, dated 5/02/2024 revealed an admission date of 04/08/2024 with diagnoses which included type 2 diabetes, and neuropathy (the nerves that are located outside of the brain and spinal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents were free from significant medication errors for 4 of 12 residents (Residents #13, #32, #33 and #285) reviewed for significant medication errors. 1. On 05/04/2024 at 07:31 AM LVN U failed to perform a safety check on the insulin injection pen prior to administering Resident #285's insulin injection. 2. On 05/04/2024 at 10:04 AM Medication Aide V administered oxcarbazepine (an anti-seizure medication), and Baclofen (an anti-muscle spasm medication) to Resident #13 late by 1 hr. and 5 minutes. 3. On 05/04/2024 at 10:09 AM Medication Aide V administered ferrous sulfide (an iron medication) and midodrine (a drug used to raise blood pressure) to Resident #32 late by 1 hr. and 9 minutes. 4. On 05/04/2024 at 10:18 AM Medication Aide V administered carbidopa-levodopa (a drug to treat Parkinson's disease) to Resident #33 late by 1 hr. and 18 minutes. These deficient practices placed residents at risk for not receiving the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility kitchen reviewed, in that: Flies too numerous to count were observed in and around the food preparation area. This deficient practice could affect residents, staff, and visitors who consume foods prepared in the facility kitchen. The findings were: Observation on 05/01/2024 at 1:20 p.m. revealed flies too numerous to count in and around the food preparation area in the facility kitchen, and especially concentrated near a box of fresh bananas. During an interview with Dietary Aide Y, at the same time as the observation, Dietary Aide Y stated, There are always flies all over the place in here [the facility kitchen]. Record review of the pest control visit logs revealed the pest control company visited bimonthly. Record review of the facility policy and procedure, titled Pest Control, effective date February 2017, revealed: 1. The community maintains an effective pest control program so that the community is free of pests and rodents. An effective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide maintenance services necessary to maintain a comfortable interior for 1 of 8 Residents (Resident #182) who was observed for homelike environment. The facility failed to ensure Resident #182's bathroom was free of bad odors since admission. This deficient practice could affect any resident and contribute to feelings of hopelessness. The findings were: Review of Resident #182's face sheet, dated 5/3/24, revealed she was admitted to the facility on [DATE] with diagnoses including Depression Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Generalized Anxiety Disorder (condition with exaggerated tension, worrying, and nervousness about daily life events). Review of Resident #182's baseline Care Plan, dated 4/25/24 revealed she was a new admission and no cognitive impairment was noted. Review of Resident #182's progress note dated 5/2/24 revealed she discharged from the facility on this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to have physician for the resident's immediate care for 1 of 8 Residents ( Resident #185) whose records were reviewed for new orders. 1. Nursing staff failed to obtain an order for the use of side rails for Resident #185 upon admission, 4/19/24. These deficient practices could affect any resident who was a new admission and could result in residents not receiving the treatment as needed or result in not obtaining physician orders for the use of equipment. The findings were: 1. Review of Resident #185's face sheet, dated 5/1/24, revealed she was admitted into the facility on 4/19/24 with diagnoses including Traumatic Subarachnoid Hemorrhage without loss of Consciousness, subsequent encounter and Unspecified Dementia ( is a group of symptoms affecting memory, thinking and social abilities). Observation and interview on 04/30/24 at 12:04 PM revealed 1/2 bed rail up on right side; close to the window and 1/4 side rail up on left side of the bed. Resident #185 was not in the room. Interview with the DON revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 1 of 3 Residents (Resident #183) whose record were reviewed for pressure ulcers. Nursing staff failed to apply a prevalon boot (designed with an open, floated-heel design which means the heel is completely floated. This provides continuous pressure relief) or offload Resident #183's left foot, on 4/30/24 and on 5/2/24, to prevent him from developing a pressure ulcer. This deficient practice could affect residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers. The findings were: Review of Resident #183's face sheet, dated 5/2/24, revealed he was admitted to the facility on [DATE] with diagnoses including Nonromantic intracranial hemorrhage (bleeding within your skull), Traumatic subarachnoid hemorrhage without loss of consciousness (is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 8 residents (Resident #183) reviewed for catheter care. CNA T lifted Resident #183's urine collection bag above the bladder during indwelling catheter care for Resident #183. This failure could place residents at risk for catheter associated urinary tract infections (CAUTI). The findings included: A record review of Resident #183's admission record dated 05/05/2024 revealed an admission date of 04/10/2024 with diagnoses which included retention of urine and urinary tract infection. A record review of Resident #183's admission MDS assessment dated [DATE] revealed Resident #183 was an [AGE] year-old male admitted for long term care with needs for an indwelling catheter care. A record review of Resident #183's physicians' orders revealed Resident #183 was prescribed an indwelling urinary catheter with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts reviewed for drug security and 1 of 8 residents (Resident #62) reviewed for medications at the bedside. 1. On 05/03/2024 LVN W was assigned the 100-hall nurse medication cart when at 08:16 AM he left the medication cart unattended and unlocked. 2. On 04/30/2024 at 11:42 AM Resident #62 had her medicated eye drops and medicated nasal spray unsecured at her bedside. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents and hazards. The findings included: 1. During an observation and interview on 05/03/2024 at 08:16 AM revealed the 100-hall nurses' medication cart unlocked and unattended by room [ROOM NUMBER], room [ROOM NUMBER] presented with the door closed. Observations of the 100-hall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review revealed the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 2 of 8 Residents (Resident #9 and #30) whose records were reviewed for lab services. 1. The facility failed to report to Resident #9's physician and document abnormal laboratory results on 02/16/2024 and again on 03/01/2024, to include low abnormal sodium blood serum levels to the physician. 2. The facility failed to report to Resident #30's physician and document abnormal laboratory results on 03/02/2024. This deficient practice could affect any resident and contribute to resident's decline of health condition by not providing the physician information necessary to be informed decisions. The findings were: 1. Review of Resident #9's face sheet, dated 05/01/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident receives, and the facility provides food that accommodates resident allergies, intolerances, and preferences for 1 (Resident #70) of 25 residents reviewed, in that: Resident #70 had an intense dislike of cheese and was served a cheese omelet for breakfast. This deficient practice could lead to diminished quality of life and weight loss. The findings were: Record review of Resident #70's face sheet, dated 05/05/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION, MUSCLE WASTING AND ATROPHY, and ANXIETY DISORDER. Record review of Resident #70's comprehensive MDS, dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #70's care plan, revised 04/08/2024, revealed a focus [Resident #70 is] at risk for nutritional deficits and/or dehydration risks r/t Chronic comorbidity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #62) of 25 residents reviewed, in that: A bottle of prune juice which has been opened and was unrefrigerated, unlabeled, and undated was found on Resident #62's bedside table. This deficient practice could lead to illness due to foodborne pathogens. The findings were: Observation on 04/30/2024 at 11:42 a.m. of Resident #62's bedside table, revealed a bottle of prune juice which has been opened and was unrefrigerated, unlabeled with the resident's name, and undated. Further observation of the bottle revealed a manufacture's label which stated, Refrigerate after opening. During an interview with Resident #62, at the same time as the observation, Resident #62 stated that she drinks prune juice to alleviate constipation. The resident stated that her niece brings it to her and confirmed that she does not have a refrigerator and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation is made if the events result in serious bodily injury, to the State Survey Agency for 2 of 7 residents (Resident #1 and Resident #2) reviewed for reporting. 1. The facility failed to report to the State Survey Agency (HHSC) allegations of neglect resulting in serious bodily injury during an incident involving Resident #1 on 2/4/24 within the specified timeframe. 2. The facility failed to report to the State Survey Agency (HHSC) allegations of neglect resulting in serious bodily injury during in incident involving Resident #2 on 3/4/24 within the specified timeframe. This failure could place all residents at increased risk for potential neglect due to unreported allegations of neglect. Findings included: 1. Record review of Resident #1's admission Record, dated 3/20/24, revealed the resident was initially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There were two 5-lb. containers of commercially prepared salads in the walk-in cooler that were past their use-by dates. 2. There was an open bag of dry cereal in the dry storage room that was not stored in a closed or tightly covered container. 3. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. 4. [NAME] C wore a wristwatch on her arm while preparing food in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 03/21/2023 at 10:35 a.m. in the walk-in cooler revealed there was one 5 lb. container of commercially prepared tuna salad and one 5 lb. container of smoked chicken salad. Both containers were half full, and both containers were labeled 3/06/2023. There was no use by date on either container. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to accurately reflect the resident's status on the MDS assessment for one resident (#16) of 8 residents reviewed for MDS assessments in that: Resident #16 was admitted with a cardiac pacemaker and it was not reflected on his MDS assessment. This deficient practice could affect residents with active healthcare devices and could result in equipment malfunction and heart failure. The findings were: Review of Resident #16's electronic face sheet dated 03/22/2023 revealed he was admitted to the facility on [DATE] with diagnoses of closed fracture (when bone breaks and no puncture or open wound in the skin), pain in left hip (discomfort in left hip), and paroxysmal atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of Resident #16's admission MDS assessment dated [DATE] revealed he did not have cardiac pacemaker listed under active diagnoses. He scored a 15/15 on his BIMS which indicated he was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to assure that residents receive a therapeutic diet as prescribed by the physician for one resident (#36) of 8 residents reviewed for diets in that: Resident #36 was prescribed a renal diet (A renal diet is one that is low in sodium, phosphorous, and protein. A renal diet also emphasizes the importance of consuming high-quality protein and usually limiting fluids. Some patients may also need to limit potassium and calcium) and was provided a regular diet which did not meet his special dietary needs and was provided a regular diet. This deficient practice could affect residents who are prescribed renal diets and could result in potassium building up in the blood stream and could result in a heart attack. The findings were: Review of Resident #36's electronic face sheet dated 03/22/2023 revealed he was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (a metabolic disorder in which the body has high sugar levels for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (#63) out of 6 residents observed for medication pass in that: LVN A put her bare finger in the medication cup and carried the cup back and forth up and down the hall twice with her hands over the rim of the cup prior to giving Resident #63 her medications. This deficient practice could affect residents who receive medications and could result in cross contamination and the spread of infection. The findings were: Review of Resident #63's electronic face sheet dated 03/22/2023 revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a brain disorder that gets worse over time), atherosclerosis of aorta (condition where arteries become narrowed and hardened due to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.